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date: 14 August 2018

Health Diplomacy in the Political Process of Integration in Latin America and the Caribbean

Summary and Keywords

The construction of the concepts of diplomacy and health diplomacy must consider their conceptions and practices, at both the global and regional levels. Health diplomacy is vitally important in a global context, where health problems cross national borders and more new stakeholders appear every day, both within and outside the health sector. On the other hand, regional integration processes provide excellent opportunities for collective actions and solutions to many of the health challenges at the global level. In the current global context, the best conditions for dealing with many health challenges are found at the global level, but the regional and subregional spheres also play essential roles.

The region of Latin America and the Caribbean (LAC) consists of 26 countries or territories that occupy a territory of 7,412,000 square miles—almost 13% of the Earth’s land surface area; it extends from Mexico to Patagonia, where about 621 million people live (as of 2015), distributed among different ethnic groups. Geographically, it is divided into Mexico and Central America, the Caribbean, and South America, but it presents subregions with populations and cultures that are a little more homogenous, like the subregions of the Andes and the English Caribbean. By its characteristics, LAC has acquired increasing global political and economic importance.

In the 1960s, integration processes began in the region, including the creation of the Union of South American Nations (UNASUR), Mercosur, the Andean Community, the Caribbean Community (CARICOM), the Central American System, the Bolivarian Alliance for the Peoples of Our America (ALBA), the Amazon Cooperation Treaty Organization (ACTO), the Sistema Económico Latinoamericano y del Caribe (SELA), the Asociación Latinoamericana de Integración (ALADI), and finally, since 2010, the Community of Latin American and Caribbean States (Comunidad de Estados Latinoamericanos y Caribeños, or CELAC), which is the most comprehensive integrative organization.

While originally a mechanism for political and economic integration, health is now an important component of all the abovementioned integration processes, with growing social, political, and economic importance in each country and in the region, currently integrating the most important regional and global negotiations.

Joint protection against endemic diseases and epidemics, as well as noncommunicable diseases, coordination of border health care, joint action on the international scene (particularly in multilateral organizations such as the United Nations and its main agencies), and the sectoral economic importance of health are among the main situations and initiatives related to health diplomacy in these integration processes.

The effectiveness of integration actions—and health within those actions—varies according to the political orientations of the national governments in each conjuncture, amplifying or reducing the spectrum of activities performed. The complexity of both the present and future of this rich political process of regional health diplomacy is also very important for global health governance (GHG).

Diplomacy is the art and practice of conducting negotiations among representatives of states. According to Seely (2016), states use diplomacy to solve disputes, form alliances, negotiate treaties, strengthen economic relations, promote cultural and military exchanges, and a variety of other purposes. For centuries, international diplomacy has focused primarily on resolution of territorial conflicts between countries or other conflicts involving high-profile economic and trade issues.

Health first entered diplomatic negotiations in the 19th century for economic reasons, due to pandemic diseases such as cholera, plague, yellow fever, and others that were hindering and even paralyzing international trade due to the illness and deaths of entire ship crews and the populations of port cities (Rosen, 1993; Benchimol, 1999; OPS, 1992). Problems involving economic and social spheres and the health-disease process have multiplied during the last 150 years. Starting in the mid-19th century (when the Americas and the rest of the world first realized the need to negotiate medically and diplomatically on issues linking societies, economies, and disease) and continuing to this day, hundreds of new issues have emerged for diplomatic negotiations involving health.

In the approach to health diplomacy in the political process of integration in Latin America, various concepts that require definition are used. In this section, we will focus our attention particularly on the areas of health diplomacy, global governance, global health governance (GHG), and global governance for health (GGH), and integration.

Health Diplomacy

Health diplomacy is defined as “a political change activity that meets the dual goals of improving health while maintaining and strengthening international relations abroad,” and as a “chosen method of interaction between stakeholders engaged in public health and politics for the purpose of representation, cooperation, resolution of disputes, improvement of health systems, and securing the right to health for the entire population” (Lee & Smith, 2011, pp. 9–10).

According to Katz, Kornblet, Arnold, Lief, and Fischer (2011), the term global health diplomacy has numerous and vastly different meanings, falling into three different categories of interaction in international public health issues: (a) core diplomacy (i.e., formal negotiations between and among nations); (b) multistakeholder diplomacy (i.e., negotiations between or among nations and other actors, not necessarily intended to lead to binding agreements); and (c) informal diplomacy (i.e., interactions between international public health actors and their counterparts in the field, including host-country officials, nongovernmental organizations, private-sector companies, and the public).

Health diplomacy can be considered a method for establishing multistakeholder commitment and consensus on health issues and their determinants that cross national borders, usually related to political power and economic interests, but also involving various types of values and principles. Like all diplomacy, it is an essentially political process, in which health plays an increasingly important role.

Health diplomacy requires expertise in such fields as public health, international relations, public administration, international law, and political economics. It also focuses on negotiations involving foreign affairs, trade, and other political and global determinants of health.

Health diplomacy enjoyed enormous development throughout the 20th century, extending inexorably into the early 21st century as the result of the prevailing and complex globalization process. Health diplomacy is increasingly an issue for diplomacy as a whole and a key dimension in the processes of global governance, GHG, and GGH, due to its growing political, economic, and ethical importance in relations among countries.

Global Governance, GHG, and GGH

Rosenau (1995) defines governance as the method by which organized societies direct, influence, and coordinate the activities of multiple public and private actors to achieve collective goals. The notion of governance extends beyond the formal mechanisms of government and refers to the totality of ways by which a society organizes and collectively manages its affairs. Government is a specific and highly formalized form of governance.

As highlighted by Frenk and Moon (2013, p. 937), global governance is the extension of this notion to the world as a whole. “It can refer to the formal decision-making processes of the United Nations (UN) Security Council, for example, or to less formal ways of influencing behavior . . . and includes the myriad processes that shape the way we collectively address issues of global significance, such as financial stability, environmental sustainability, peace and security, human rights, and public health.”

The same authors (p. 937) add that “global governance is different from national governance in one critical respect: there is no government at the global level. . . . There is no hierarchical political authority, or world government, that has jurisdiction over the nation states.” Still, since its creation in 1948, following World War II, the United Nations is the structure that most resembles a political and legal order for global governance.

Meanwhile, health governance concerns “the actions and means adopted by a society to organize itself in the promotion and protection of the health of its population” (Dogson, Lee, & Drager, 2002, p. 6), as distinguished from the concept of GHG, which “in standard usage, is limited to the norms and institutions that operate within the health sector—for example, norm development by international health organizations such as WHO and UNAIDS” (Gostin, 2014, p. 72). Health governance traditionally has been associated with the national and subnational levels, at which countries assume the responsibility for the population’s health within their territories.

In this sense, global (or regional) health governance is largely exercised by the UN agency that specializes in health, the World Health Organization (WHO) (created in 1948 along with the United Nations), as well as its regional agencies, such as the Pan American Health Organization (PAHO) in the Americas. Still, the growing complexity of health and the political and economic interests affecting it over the course of the late 20th and early 21st centuries has brought a myriad of new stakeholders to the health governance scene at the global, regional, national, and even local levels.

Meanwhile, GGH involves a more comprehensive concept that extends beyond the health sector, defined as “the collection of rules, norms, institutions, and processes that shape the health of the world’s population” (Gostin, 2014, p. 72). This concept acknowledges the influence of numerous other government sectors, private companies, and civil society movements in relation to health, including education, agriculture, housing, industry and commerce, and environment, thus requiring their accountability vis-à-vis the impact of their policies on the population’s health and quality of life.

Health diplomacy, with its various tools for action, is the political and technical sphere responsible for negotiations between governments of countries and other relevant political actors to make global governance and GHG work in favor of the best possible results for the population’s health.

Integration

The word integration has its origins in the Latin integrationem, meaning the act and effects of integrating, becoming part of a whole, and joining or forming part of a group. CEPAL (2014, p. 10) defines regional integration as “a multidimensional process which may take the form of coordination, cooperation, convergence, and deep integration initiatives and whose scope extends not only to economic and trade issues but to political, social, cultural, and environmental ones as well.”

Regional integration processes, especially in their political and governance dimensions, have been the object of numerous books and articles in the specialized literature in international relations, as illustrated by the growing interest sparked by the characteristics and challenges of regionalisms such as the European Union, African Union, and Union of South American Nations (UNASUR). For example, Riggirozzi and Tussie (2012) studied health as part of regional integration, providing an in-depth, empirically driven analysis of current models of regional governance in Latin America that emerged from the crisis of liberalism in the region.

The Origin of Health Diplomacy in LAC

In the 1870s, a yellow fever epidemic swept through Brazil, Paraguay, Uruguay, and Argentina, causing 15,000 deaths in Buenos Aires alone. In 1878, the disease struck the Mississippi Valley in the United States via the region’s maritime foreign trade, causing some 100,000 cases and 20,000 deaths (OPS, 1992). To deal with this dire situation, the countries of the Americas met in Washington, DC, for the 5th International Conference in 1881 to deal with this and other emerging global and regional health threats.

The year 1890 witnessed the formal organization of inter-American political cooperation with the convening of the First International Conference of American States, held in Washington, DC, which established the International Union of American Republics (which today is the Organization of American States), with a focus on trade between the countries. However, due to the persistence of adverse health conditions, the 2nd Conference, held in Mexico City in October 1901, recommended that the Union call “a general convention of representatives of the health organizations of the different American republics” to formulate “sanitary agreements and regulations” (OPS, 1992) and to hold periodic health conventions. The same general convention was also charged with naming a permanent executive board of no fewer than five members, to be called the “International Sanitary Bureau,” with headquarters in Washington, DC (OPS, 1992).

In December 1902, convened by the Bureau in Washington, DC, the First General International Sanitary Convention of the American Republics included participation by 11 countries. Despite the term international, such conventions were actually regional; subsequent meetings were entitled Pan American Health “Conferences,” held on average every four years. The 2nd Convention was held in 1905, establishing regular operating procedures and an important agreement, the Washington Sanitary Convention, which set standards for the control of epidemic diseases. In 1907, the 3rd Sanitary Convention was held for the first time outside of Washington DC, in Mexico City, following the International Sanitary Conference (held in Rome the same year), which had established the Office International d’Hygiène Publique (OPS, 1992).

The result of this process in the Americas was the institutionalization, in 1902, of the Pan American Sanitary Bureau (OPS, 1992), the first regional international health structure (i.e., the first institution in the world dedicated to health diplomacy), as the space for negotiations on health between national states. The creation of this institution resulted from growing international trade, medical progress, and new political and diplomatic relations among the nations of the Americas (Brown, Cueto, & Fee, 2006). Importantly, this health diplomacy structure or space for high-level negotiations in the field of health was essentially born from the diplomatic sphere, thus illustrating the close relations between diplomacy and health since the genesis of the health-sector diplomatic structure, as well as the importance ascribed by diplomacy to the theme of health.

Throughout the 20th century, given the world’s growing political and health-related complexities, the relations between diplomacy and health converged even more, culminating in the creation of the WHO as the UN agency specializing in health. For an overview of global health diplomacy and its evolution over the course of the 20th century and its challenges in the 21st century, see Kickbusch and Kökény (2013).

The Development of Global Health Diplomacy in Recent Years

The 21st century has witnessed an increased focus on the concepts and contemporary practice of health diplomacy, multistakeholder perspectives, multidirectional phenomena and interventions, and the implementation of joint solutions in global health. As discussed previously, the main issue on the global agenda in the past was responding to communicable diseases. Today’s agenda includes a wide range of issues, such as the effects of globalization on the epidemiological transition, antimicrobial resistance, noncommunicable diseases, social determinants, global climate change, food insecurity, and the need to strengthen universal and comprehensive health systems. The idea is not only to understand the effects of globalization on health, but also to structure joint global responses to these problems by government and civil society stakeholders.

The Oslo Ministerial Declaration (Amorim et al., 2007), convening the ministers of foreign affairs of South Africa, Brazil, France, Indonesia, Norway, Senegal, and Thailand, highlighted the growing role of health in foreign affairs. The ministers acknowledged the need for new forms of governance to support development, peace, and security, favoring the approach to intrinsic global health issues in international relations and global policies. Because of health’s growing global role, important resolutions were reached in the United Nations,1 involving WHO at the global level and the regional offices in the regional integration processes. The challenges for global health diplomacy feature the International Health Regulations (WHO, 2005), the binding instrument of international law for preventing and controlling public health risks that cross national borders and that represent global public health threats, which require countries to report outbreaks of certain diseases to WHO to coordinate joint responses2.

Another groundbreaking result of global health diplomacy negotiations was the WHO Framework Convention on Tobacco Control (FCTC), which developed a strategy to reduce the demand for and supply of tobacco products, thereby responding to the global tobacco epidemic facilitated by a range of complex factors with cross-border effects, including the existence of powerful, transnational tobacco corporations, trade liberalization, global marketing, and international contraband and counterfeiting of cigarettes. Based on the World Health Assembly’s negotiation of the Global Strategy and Plan of Action on Public Health, Innovation, and Intellectual Property (2011)3, health incorporated a theme that, until then, had been addressed exclusively by an organization that did not follow a public health logic per se (World Intellectual Property Organizations/WTO). This shift highlighted the complex negotiations in health diplomacy, with tensions between public health, economic interests, international trade, and foreign policy.

Another reference in health diplomacy is globalization, a complex phenomenon with economic, social, political, and cultural dimensions that tends to erase the distinctions between national and global problems or issues. Within these processes, population movements accelerate, borders disappear, global markets emerge, a virtual culture is consolidated, transnational corporations are installed, and there is a reordering of the United Nations, accentuating the spread of infectious and contagious diseases, as well as the dissemination of unhealthy lifestyles involving risk behaviors. It is thus necessary to combine international efforts to reduce risks and take advantage of health opportunities, assuming that the responses to the flow of health problems extend beyond national borders. The process thus requires collective action, applying various forms of cooperation.

As reported in The Lancet, according to the Lancet—University of Oslo Commission on Global Governance for Health (Ottersen et al., 2014), a wide range of global and political determinants of health involves such aspects as trade, international investments, financial and economic regulation, environment, labor, knowledge and intellectual property, international security, and international conflicts and disasters, among others, which includes more actors and alliances in negotiations where the interests can often clash with, undermine, or generate inequities in health,

Health also has become a highly important space for the production and accumulation of capital, thus making the medical financial and industrial complex (consisting of private corporations that make profit from diseases) a central player in global health policies (Manso de Mello Vianna, 2002)4. The return to neoliberal policies, with adjustment of public spending, global environmental changes, deteriorating health conditions due to climate change, population movement, the regular trade of harmful products (tobacco and alcohol) and illegal products like drugs, and the dissemination of medical technologies, poses new challenges for health. In this context, the best conditions for managing many of the current health challenges from globalization are found at the global level, while the regional and subregional levels also play essential roles. Various relevant processes of economic and political integration have taken place with different levels of development throughout LAC.

Latin American Integration

The proposal for a Latin American Union is old, having been launched with the various movements for political independence in the countries on the continent, with the implosion of the Spanish and Portuguese empires in the early 19th century. In the name of the new nations’ liberty and independence, Simón Bolívar drafted a proposal for regional unity that included the formation of a Federation of Republics, a common defense system, and an economic and monetary union. In the wake of numerous defections, the proposal never materialized, but it is still considered the first manifestation of a regional integrationist movement in Latin America (Bethel, 2008).5

More recently, and specifically in the last 70 years, Latin America has witnessed forces for integration that have achieved greater institutional consolidation. The concept of regional economic integration was developed in the 1950s as a key component in the thinking of the United Nations Economic Commission for Latin America and the Caribbean (ECLAC)6. Based on this integrationist influence and orientation, the following occurred in the early 1960s:

• In Central America, the Organization of Central American States7 established the Central American Common Market in 1960 and became the Central American Integration System (Sistema de Integración Centroamericana, or SICA) in 1991.

• In Latin America as a whole, the Latin American Free Trade Association (LAFTA), or Associação Latino-Americana de Integração (ALALC), was created, also in 1960; later, in 1980, it was transformed into the Latin American Integration Association (LAIA), or Asociación Latinoamericana de Integración (ALADI).8

• the Caribbean Community (1973),10 a more sustained measure for regional integration in the Caribbean after earlier efforts at establishing a political union (the West Indies Federation in 1958) and the Caribbean Free Trade Association (CARIFTA) in 1965.

• MERCOSUL (the Southern Common Market)11 was established in 1991, which included the continent’s Southern Cone countries.

The abovementioned institutions were markedly oriented toward economic and trade issues. The presence of social sectors and themes—including health—only occurred more recently, due to more progressive governments and political pressure from social movements responding to the extremely unequal social and economic reality in the LAC countries. With the European Union as a model (Guimarães Queiroz, 2007), a concept of largely economic and commercial integration prevailed throughout the 1990s. Following the European model, the processes developed in the Americas proposed the countries’ assimilation by the free market economies. These modalities of economic integration proposed the establishment of preferential tariff agreements, free trade zones, customs unions, common markets, and economic and monetary unions. In this sense, integration is associated with the idea of shaping a broad economic space, beyond the nation states, and overcoming trade barriers.

The early 21st century has seen new processes of integration that have not only an economic nature, but also social, cultural, political, and ideological dimensions. These approaches to integration were associated with the rise of popular presidents who questioned neoliberal policies and the market as drivers for development. Luiz Inácio Lula da Silva in Brazil, Néstor Kirchner in Argentina, Evo Morales in Bolivia, Hugo Chávez in Venezuela, and Rafael Correa in Ecuador, among others, shared interests and a set of ideas and values that allowed the emergence of new government practices to improve income distribution and social services, with strong state leadership.

The Bolivarian Alliance for the Peoples of Our America (ALBA),12 UNASUR,13 and the Community of Latin American and Caribbean States (Comunidad de Estados Latinoamericanos y Caribeños, or CELAC)14 are some examples of these more political processes of integration. From their origins (constitutive principles and structure), these integration processes have not taken into account economic aspects, but rather considered the supremacy of political and social issues. Castro (2015) questions whether integration in LAC is emancipatory or an expression of neocolonialism. The reasons for regional integration in LAC cited by Bauman (2011) remain valid; they include expanding market access, absorbing gains from scale, fostering the provision of regional public goods, improving competition in the domestic market by reducing oligopolistic gains, improving negotiating capacity in international forums, complementing the domestic supply of basic inputs such as energy and water, reducing bilateral exchange rate imbalances, and improving the attractiveness for potential foreign investors (Bauman, 2011).

Still, in the specific case of Latin America, more time is needed to adequately address the following questions: What factors have enabled or constrained transformative Latin American regionalism with respect to the powers and policies of states participating in it? What factors will determine how resilient Latin American regionalism is likely to be under changing political and economic conditions?

Processes of Regional Integration and Health in LAC

In the current globalized context, the regional level provides an opportunity to address the social determinants of health, joining efforts and fostering collective and diplomatic action in the field of health. Riggirozzi (2014) argues that regional organizations can become the prime spaces for collective action, as pivotal actors in the advocacy of rights (to health), enabling diplomatic and strategic options to member-states and nonstate actors and playing a role as a deal-broker in international organizations by engaging in new forms of regional health diplomacy.

Regional health diplomacy has been analyzed by Latin American authors from different angles and perspectives (Buss & Ferreira, 2011; Carrillo Roa & Santana, 2012). Regional health diplomacy is characterized essentially by the presence of political actors, mainly from ministries of health, who conduct negotiations to influence the global, political, and economic determinants of health, addressing problems that extend beyond their own countries’ borders. Such diplomacy involves negotiations within the framework of health-sector forums of integration, such as meetings of ministers of health or experts from these agencies that are aimed at contributing to the region’s health. Table 1 lists the leading initiatives in regional integration in LAC and the issues that they have addressed concerning health.

Table 1. Initiatives in Regional Integration and Health in LAC

Name and Year of Implementation

Description

Health Issues

CELAC, 2010

CELAC was created during the Summit on Unity of Latin America and the Caribbean, held in Riviera Maya, Mexico, in February 2010.

Does not have a specific health division.

Actions by CELAC on the subject of health began with the epidemic threats of the Ebola and Zika viruses.

Committed to implementing the Framework Convention on Tobacco Control in the region.

Promotes food and nutritional security, recognizing poverty as the leading cause of hunger and the need for public services to overcome it.

UNASUR, 2004

UNASUR was created by the Cuzco Treaty.

Has a South American Health Council, with the ministers of health of the 12 countries of South America.

The vision of the UNASUR Five-Year Health Plan is to consolidate South America as a space for integration that contributes to health, with five strategic lines:

I. South American Epidemiological Shield

II. Universal Access to Medicines

III. Development of Universal Health Systems

IV. Development of Human Resources

V. Determinants of Health

Has a South American Institute for Health Governance (Instituto Sul-Americano de Governo em Saúde, or ISAGS), which acts as the center for high-level studies and public policy debate.

The actions of ISAGS contribute to the development of health governance and leadership in UNASUR.

MERCOSUR, 1991

The Southern Common Market was created by the Treaty of Asunción (by Argentina, Brazil, Paraguay, and Uruguay) for the free circulation of goods, services, and inputs, the establishment of a common foreign tariff, coordination of macroeconomic and sectorial policies, and harmonization of legislation in the corresponding areas. Subsequently incorporated in Venezuela.

Has two forums that deal with health: Sub-Group No. 11 on Health and Meetings of Ministers of Health of MERCOSUR.

Sub-Group No.11 on Health is the organization that harmonizes the respective national legislations on matters pertaining to health regulation, including compatibility of health control systems among the member-states. Harmonizes quality parameters and standards for goods, services, and inputs in the health area, with the aim of eliminating technical barriers to trade and strengthening regional integration.

The Meetings of the Ministers of Health of MERCOSUR act as forums for joint priority-setting and the adoption of shared solutions and measures to promote health policies. Sub-Group No.11 on Health has prioritized the implementation of the FCTC and IHR (WHO, 2005), vector-borne diseases, HIV/AIDS, sexual health, transfusion and transplants, medicines, and social determinants, among others.

CAN, 1969

The Andean Community of Nations was created by the Cartagena Agreement to improve the living standards of its inhabitants through integration and economic and social cooperation.

Has the Meeting of Ministers of Health of the Andean Area and specialized body in health, called the Andean Health Organization/Hipólito Unanue Agreement (Oras-Conhu). The member-states are Bolivia, Colombia, Ecuador, and Perú, although Chile and Venezuela also participate in the health-sector forums.

Oras-Conhu (Andean Health Organization—Hipólito Unanue Agreement) is an organization dedicated to meet and make arrangements on health that allows conducting coordinated actions dedicated to managing common problems and contributing to ensuring the right to health of the peoples.

Its Strategic Plan promotes the following areas:

I. Epidemiological Shield (Andean Network of Epidemiological Surveillance and Andean Network of National Institutes of Public Health)

created by Bolivia, Brazil, Colombia, Ecuador, Guyana, Peru, Surinam, and Venezuela, acknowledges the cross-border nature of the Amazon region. It promotes harmonious development of the region and the incorporation of these territories in the respective national economies.

Has a Special Commission of the Amazon Region on Health (Centro de Estudos do Ambiente e do Mar, or CESAM), with the following objective: to improve health conditions through policies to eradicate epidemics in the region.

The Strategic Plan prioritizes the following:

I. Coordination with other initiatives for integration of the region

II. Epidemiological surveillance

III. Environmental health; health determinants in the Amazon

IV. Stimulus, strengthening, and consolidation of research in the Amazon

V. Financing the health agenda

Has a Pan-Amazonian Network of Science and Technology in Health, which groups academic institutions from the area to conduct research and development projects and human resources training and specialization.

ALBA, 2001

ALBA, created in 2001, emphasizes solidarity, complementariness, justice, and cooperation in order to generate structural changes and the system of necessary relations to achieve full development, in order for its members to continue being sovereign and just nations. The member-states are Venezuela, Cuba, Bolivia, Nicaragua, Ecuador, Dominica, Saint Vincent and the Grenadines, Antigua and Barbuda, and Saint Lucia. It does not have a specific health body, but there is a Ministerial Council for Social Programs.

Three projects have been approved in the health area:

I. Grand National Project for the Creation of the Regulatory Center for Essential Medicines, ALBA (Albamed) to develop and implement a single, harmonized, and centralized system dedicated to registration of medicines

II. Creation of a Grand National Company for Distribution and Commercialization of Pharmaceutical Products for fair trade of medicines

III. Program for Psychosocial Genetic Clinical Study of Persons with Disabilities to promote the nondiscriminatory integration of persons with disabilities and promote their individual potentialities.

Promoted Operation Miracle to defend the right to health and a decent life through surgeries devoted to recovering the sight of persons affected by cataracts and other neglected diseases, free of cost and with solidarity.

SICA, 1991

SICA seeks the integration of Central America as a region of peace, freedom, democracy, and development supported by respect for and protection and promotion of human rights. The member-states are Belize, Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua, Dominican Republic, and Panama.

SICA has a Council of Ministers of Health of Central America and the Dominican Republic, which drafted and approved the Central American Health Agenda and Plan.

The Central American Health Agenda and Plan seeks to strengthen the social integration of Central America and the Dominican Republic through the implementation of regional health policies; strengthen social protection; guarantee access to health services with quality; reduce inequalities and inequities and social exclusion in health within and between countries; reduce the risks and burdens of communicable and noncommunicable diseases, gender and social violence, environment, and lifestyles; strengthen health workers’ management and development; promote research and development of science and technology and the use of scientific evidence in crafting health policies; strengthen health and nutritional security; establish mechanisms to increase the coverage of water supply and environmental improvement and protection; and reduce vulnerabilities to natural disasters and emergencies due to climate effects.

CARICOM, 1973

CARICOM, created in 1973 by the Treaty of Chaguaramas, replaced the Caribbean Free Trade Association, created in 1965.

Includes the following nations and dependencies: Antigua and Barbuda, Barbados, Belize, Dominica, Granada, Guyana, Haiti, Jamaica, Montserrat, Saint Kitts and Nevis, Saint Lucia, Saint Vincent and the Grenadines, Suriname, Trinidad and Tobago, British Virgin Islands, and Turks and Caicos.

Aims to promote economic integration and cooperation among its members, as well as ensuring that the benefits of integration are distributed equitably and coordinating a common foreign policy. Develops activities that include the coordination of economic policies and planning and development, besides the implementation of special projects for less-developed countries. Functions as a single regional market for many of its members and as a forum for dispute resolution.

Has a Council on Human and Social Development (COHSOD), which includes Health. CARICOM approved Caribbean Cooperation in Health, a regional health strategy that has prioritized preventing communicable and noncommunicable diseases and strengthening health systems, environmental health, food and nutrition, mental health, family and children’s health, and human resources training.

The main initiatives by CARICOM in the area of health include the Pan Caribbean Partnership Against HIV and AIDS (PANCAP) and the Caribbean Public Health Agency (CARPHA), a regional public health institute founded in 2010 with the purposes of health emergency response preparedness, public health leadership, and action in the areas of information, education, communication, research, policymaking, training, laboratory services, health surveillance and analysis, human resources development and training, and planning and mobilization of resources.

Source: Elaborated by the authors, based on various sources (webpages and reports from the mentioned organizations).

Integration processes draw on health governance mechanisms with participation by experts from the ministries who act as focal points for each of the themes and policy representatives that harmonize and coordinate positions, based on consensus rather than voting. Health forums such as the Meetings of Ministers of Health of MERCOSUR, Meetings of Ministers of the Andean Area, South American Health Council, and Council of Health Ministers of Central America and the Dominican Republic (Comisión de Ministros de Salud de Centro América, or COMISCA), among others, provide an appropriate framework for debate, information-sharing, consensus-building, and the development of joint strategies to coordinate actions and cooperate in order to overcome barriers to access and increase health policy efficacy. Table 2 lists some of the achievements of regional integration in health.

The opportunity to identify common problems extending beyond the countries’ national borders, as well as to structure shared responses, such as regional strategies for dengue, Zika, and chikungunya elaborated under UNASUR, MERCOSUR, and other organizations.

Criteria for a common approach to fighting diseases

In the elaboration of common regional strategies, common criteria are established for dealing with certain diseases, defining vulnerable groups. As an example, in the context of the H1N1 influenza pandemic, UNASUR member-states define priority populations for immunization, promote a strategy for access to the vaccine, and harmonize surveillance and control algorithms.

Opportunity for the production of regional public goods

Identification of common problems and shared responses has created the possibility of innovation to the extent that the responses benefit all, and that their use by one country does not harm another. An example in MERCOSUR is the development of an Image Bank for tobacco prevention campaigns, whose content can be used independent of copyright by any of the member-states.15

Appropriate mechanism for public health emergencies and pandemics

In the H1N1 influenza pandemic, the possibility of emergence of Ebola cases in the region, and contingencies of natural disasters (earthquakes and others), integration in health has provided preparatory mechanisms to address and mitigate the problems and to distribute humanitarian aid.

Information and knowledge production

Regional integration has proved to be a virtuous mechanism for exchanging information about the priority of diseases and policies to respond to them, and as a window of opportunity for feedback on the policymaking processes and cooperation among the countries.

Consensus-building

Prime opportunity for consensus-building based on the principles of equity and solidarity, with health as a fundamental right, as in the initiative by SICA entitled “Health: A Bridge to Peace for Central America,”16 and the Declaration of Belize, according to which health “can and should be . . . a source for the development process.”

Innovative institutional designs

The creation of innovative institutional designs for the management of training, critical reflection, knowledge management, and human resources training. Examples include ISAGS17 and CARPHA18 under CARICOM. The institutions are strategically valuable for training and improving human resources, knowledge production on strategic issues, and cooperation in health.

Regional negotiations on access to medicines

Facilitators for regional price negotiations and joint procurement of medicines for malaria,19 antiretroviral drugs for HIV/AIDS20, and high-cost medicines, as well as for building databases of prices, allowing greater efficiency in purchases by the member-states’ Ministries of health map the capacities for health inputs in the UNASUR countries, with the purpose of promoting public production and generating complementary roles in the production of medicines, vaccines, and strategic inputs.

More effective global health diplomacy

Allow more effective health diplomacy, harmonizing common positions for participating in multilateral organizations that address health-related issues. An example is UNASUR’s position in WHO on intellectual property issues, counterfeit products, misleading labeling, and substandard quality. Perhaps the most significant case is that of the CARICOM countries: at each PAHO meeting, the Caribbean ministers of health harmonize their positions in advance and always participate as a bloc.

Opportunities for networking

Regional integration has fostered networking,21 allowing a model of horizontal cooperation for capacity-building or project development. Examples are the networks of health systems’ structuring institutions, such as the Network of National Health Institutes/Rede de Institutos Nacionales de Salud (RINS/UNASUR),22 the Network of Schools of Public Health/Rede de Escuelas de Salud Pública (RESP/UNASUR),23 Network of National Cancer Institutes/Rede de Institutos Nacionales de Cancer (RINC/UNASUR),24 Network of Polytechnic Health Schools/Rede de Escuelas Politecnicas de Salud (RETS/UNASUR)25, and others. These networks have enormous potential to contribute to human resources training, research and technological development, and provision of reference services in the region.

Institutional Designs and Health Diplomacy

As discussed previously, the current scenario calls for stepping up relations between health and areas such as trade, intellectual property, finance, and biosafety. Health’s complexity in the national scenario increasingly reflects the global scale and vice versa, raising the need for coordinated, linked, and negotiated actions. Thus, health and international relations have developed closer relations and are increasingly present in the institutional designs of the various ministries of health and foreign affairs. For global health diplomacy at both the multilateral and regional levels, ministries of health need to draw on systems of analysis and intelligence for managing the complexity of global health, in order to negotiate and cooperate more effectively. Global issues influence health, just as regional issues in the Americas condition international cooperation, providing an appropriate field for the development of health diplomacy. As we have seen over the course of this article, regional integration processes have spawned forums and organizations that address health and that develop important mechanisms for horizontal cooperation and networking to manage many health problems at the regional level.

Global health, at the national level of the ministries of health, needs forms of governance that allow linkage and negotiations with a wide range of stakeholders. Health diplomacy deals with these processes of negotiation that shape and administer the political environment for health and its determinants,26 involving negotiations with the ministries of foreign affairs, processes of regional integration in health, multilateral organizations, and others.

Several ministries of health in the region have thus created Offices or Departments of International Relations, with the strategic role of developing relations with all these stakeholders and exercising increasing leadership. The underlying reason or mission of these offices should be “to promote health cooperation with a wide range of stakeholders,” to “promote linkage between national health policy and foreign policy,” and to “manage participation by the Ministries of Health in global and regional health governance, as well as with other international organizations that can affect health.” (Pan American Health Organization (PAHO), 2017, p. 19).27

Training in Health Diplomacy and Cooperation in LAC

The complexity of the issues addressed in the field of health diplomacy requires training professionals in the ministries of health and foreign affairs in order for the states to have the adequate capacity to deal with the new challenges in governance, governability, and management of international cooperation for health (PAHO, 2017). To do that, in 2015, PAHO and the FIOCRUZ Center for Global Health (CRIS) promoted the Program to Strengthen Cooperation for Health Development (CCHD)28, which aimed to improve actions by the region’s centers for global health and ministries of health. The proposal seeks to analyze the current situation with the management of health diplomacy in the ministries of health and to facilitate strategies for institutional strengthening at the national level, based on the underlying concept of “structuring cooperation in health” (Almeida, Pires de Campo, Buss, Ferreira, & Fonseca, 2010).

As for the concepts’ relative novelty, a space was promoted for shared reflection among the agencies responsible for implementing activities in priority themes: health diplomacy, South-South and triangular cooperation, global and regional health governance and relations with international agencies, and global governance and health. The agenda was complemented with relevant global issues as the object of health diplomacy and cooperation, including 29 representatives from the ministries of health of 28 countries of the Americas participating in the program’s first edition.

The analytical essays developed by the program’s participants revealed a clear understanding of the action by the ministries of health and centers for global health in the field of diplomacy and international cooperation in health, while also producing proposals for changes in their structures, roles, and policies.

Final Remarks

The interdependence of countries in Latin America has increased substantially in recent decades, with greater proximities in their social and health realities. As a result, these countries are increasingly sensitive to events in neighboring countries.

The reality appears to oscillate; at times, regional integration appears to proceed largely along economic lines, while at other times, it is more linked to political and social issues, so that the progress is not apparently linear. Importantly, in nearly all the initiatives for integration, health occupies an important place, creating advantages for all the members of the blocs. These initiatives for regional integration seek to act as a means for socioeconomic development, international positioning in a globalized world, improvement in the populations’ living conditions, and impact on the determinants of health, pursuing the region’s autonomy and that of its member-states.

The subregional level at which processes of integration occur is highly important for joint efforts, coordination, and cooperation to manage the current health challenges and build a common agenda in order to guarantee the right to health for all the region’s inhabitants. Currently, for example, the common efforts in most integration processes focus on Agenda 2030 and the Sustainable Development Goals of the United Nations.

In this context, health diplomacy serves as an appropriate instrument for collective action and for influencing the global determinants of health, as well as for the production of some key global public goods in health. The examples discussed in this article demonstrate the potential advantages of these integration processes for health. Despite the widespread rallying cry to “think globally and act locally,” some of the current health challenges probably require a complementary effort in order to “think locally and act regionally.”

Regional integration processes in health provide an opportunity to build a political health community with shared values and interests, a situation that can be achieved via interaction between the member-states’ health ministers and their experts, especially by establishing consensus through the use of diplomacy in the field of health.

Notes:

(1.)
According to Resolution 64/265, the UN General Assembly decided to hold a high-level meeting of the General Assembly for the prevention and control of noncommunicable diseases. See United Nations (2010). Retrieved from http://www.un.org/es/comun/docs/?symbol=A/RES/64/265; United Nations (2010) Resolution 64/108, Global Health and Foreign Policy, in point number 2, “Recognizes the close relationship between foreign policy and global health and their interdependence, and in that regard also recognizes that global challenges require concerted and sustained efforts by the international community.” Retrieved from http://www.un.org/es/comun/docs/?symbol=A/RES/64/108; United Nations. (2011). Resolution 65/95, Global Health and Foreign Policy, calls for more attention to health as an important policy issue on the international agenda. Retrieved from http://www.un.org/es/comun/docs/?symbol=A/RES/65/95; and Resolution 66/115. Global Health and Foreign Policy, incorporates the environmental dimension as a determinant of health. United Nations (2012). Retrieved from http://www.un.org/es/comun/docs/?symbol=A/RES/66/115.

(4.)
According to Manso de Mello Vianna (2002), the term medical industrial complex (MIC) has been used in Brazil since the 1980s to refer to multiple and complex interrelations among various health-sector actors and between these actors and other sectors of the economy. The MIC is a specific historical product of health systems’ evolution. In this stage, due to the need for return on investment, private capitalist practices become hegemonic and determine each stakeholder’s functions, roles, and relations within the system. Today’s health system has two fundamental attractions that shape its stakeholders’ behavior: technology and capital appreciation. The former is the MIC, while the latter constitutes a medical financial complex.

(5.)
For a detailed discussion of the entire process of the region’s development and integration until the 1950s, we recommend Bethell (2008).

(27.)
The analysis of the mission of the Centers for Global Health in LAC was based on the analytical essays by the participants in the Program for Cooperation in Health Development. Available at Pan American Health Organization (PAHO) (2017), Programa CCHD en el Campus Virtual de Salud Pública (CVSP). Retrieved from http://cursos.campusvirtualsp.org/enrol/index.php?id=179.